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Metabolic Effects of Bariatric Surgery R Corcelles and others Bariatric surgery 174:1 R19–R28 Review MANAGEMENT OF ENDOCRINE DISEASE Metabolic effects of bariatric surgery Ricard Corcelles1,2, Christopher R Daigle1 and Philip R Schauer1 Correspondence should be addressed 1Bariatric and Metabolic Institute, Cleveland Clinic, 9500 Euclid Avenue, M61 Cleveland, OH 44195, USA and to P R Schauer 2Department of Gastrointestinal Surgery, Institute of Digestive and Metabolic Diseases, Fundacio´ Clı´nic per a la Email Recerca Biome` dica, Hospital Clinic de Barcelona, Barcelona, Spain [email protected] Abstract Obesity is associated with an increased risk of type 2 diabetes, hypertension, dyslipidemia, cardiovascular disease, osteoarthritis, numerous cancers and increased mortality. It is estimated that at least 2.8 million adults die each year due to obesity-related cardiovascular disease. Increasing in parallel with the global obesity problem is metabolic syndrome, which has also reached epidemic levels. Numerous studies have demonstrated that bariatric surgery is associated with significant and durable weight loss with associated improvement of obesity-related comorbidities. This review aims to summarize the effects of bariatric surgery on the components of metabolic syndrome (hyperglycemia, hyperlipidemia and hypertension), weight loss, perioperative morbidity and mortality, and the long-term impact on cardiovascular risk and mortality. European Journal of Endocrinology (2016) 174, R19–R28 Introduction Obesity is an epidemic on the rise. The World Health also reached epidemic levels. The National Health and European Journal of Endocrinology Organization projects that by 2015, w2.3 billion adults Nutrition Examination Survey reported that 34% of will be overweight and more than 700 million will be American adults have metabolic syndrome based on the obese (1). Obesity is associated with an increased risk of National Cholesterol Education Program Adult Treatment type 2 diabetes (T2DM), hypertension, dyslipidemia, Panel III criteria: waist circumference R102 cm (men) cardiovascular disease, osteoarthritis, numerous cancers or R88 cm (women), triglycerides R150 mg/dl, HDL and increased mortality (2). It is estimated that at least 2.8 !40 mg/dl (men) or !50 mg/dl (women), hypertension million adults die each year due to obesity-related R130/85 mmHg and fasting glucose R100 mg/dl (4). cardiovascular disease (3). Increasing in parallel with the Conventional treatments such as diet, lifestyle modifi- global obesity problem is metabolic syndrome, which has cation, exercise and pharmacotherapy have failed to Invited Authors’ profiles Ricard Corcelles is consultant surgeon, Division of Gastrointestinal Surgery, Hospital Clı´nic Barcelona, University of Barcelona, Spain. He specializes in the field of minimally invasive surgery and has dedicated part of his career to the realm of metabolic and bariatric surgery. Philip R Schauer is Chief of Minimally Invasive General Surgery and Director of the Cleveland Clinic Bariatric and Metabolic Institute. He is also Professor of Surgery at the Cleveland Clinic Lerner College of Medicine of Case Western Reserve University. In addition, he is a former president of the American Society for Metabolic and Bariatric Surgery. www.eje-online.org Ñ 2016 European Society of Endocrinology Published by Bioscientifica Ltd. DOI: 10.1530/EJE-15-0533 Printed in Great Britain Downloaded from Bioscientifica.com at 09/30/2021 11:37:21PM via free access Review R Corcelles and others Bariatric surgery 174:1 R20 achieve satisfactory sustained weight loss. In addition, the approaches. A retrospective review of the Bariatric Out- direct cost of obesity in the United States is extremely comes Longitudinal Database (BOLD) from 2007 to 2010 high, with an estimated $190 billion spent in 2010 (5). showed 79% EWL for BPD-DS compared with 67% EWL for Numerous studies have demonstrated that bariatric RYGB at 2 years follow-up (18). surgery is associated with significant and durable weight While O’Brien et al. (19) have recently reported 47% loss and associated improvement of obesity-related EWL in a cohort of 3227 patients followed over a 15-year comorbidities (6, 7, 8). Furthermore, the beneficial effects span, AGB is still considered a purely restrictive procedure of bariatric surgery on mortality, overall disease-specific with the lowest durable weight loss. For instance, a recent risk reduction and long-term quality of life are well meta-analysis by Chakravarty et al. (20) including five documented (9, 10, 11, 12). The degree of the effect on randomized controlled trials comparing AGB with other obesity-related comorbid conditions depends on the procedures concluded that AGB is associated with less bariatric surgical approach, typically classified based on weight loss. Since its introduction in 2007, SG case its restrictive and/or malabsorptive effect. Current data volumes have increased dramatically, with published from the International Federation for the Surgery of weight loss results comparable to RYGB. SG is considered Obesity and Metabolic Diseases (IFSO) reports that the a restrictive procedure; however, it has been increasingly most commonly performed procedures are the Roux-en-Y recognized to have metabolic effects similar to those gastric bypass (RYGB) (45%), sleeve gastrectomy (SG) observed after RYGB (21). A recent 5-year outcomes study (37%), adjustable gastric banding (AGB) (10%) and has reported successful SG results, with an 86% average biliopancreatic diversion (BPD) with or without duodenal EWL (22). However, other studies have demonstrated switch (DS) (2.5%) (13). This review aims to summarize the more modest long-term weight loss results (especially in effects of bariatric surgery on the components of metabolic patients with BMI O50 kg/m2), with many patients syndrome (hyperglycemia, hyperlipidemia and hyperten- ultimately requiring revision surgery for inadequate sion), weight loss, perioperative morbidity and mortality, weight loss or recidivism (23). and the long-term impact on cardiovascular risk and mortality. Complications of metabolic surgery In their systematic review and meta-analysis (the most Weight loss cited paper in bariatric surgery), Buchwald et al. (24) Historically, the primary endpoint of bariatric surgical reported exceptionally low early and late mortality rates European Journal of Endocrinology procedures has been weight loss and the reported weight after bariatric operations (0.28 and 0.35% respectively). loss achieved is generally sustained (14, 15). The overall Mortality was higher in open and conversion cases (0.30 percentage of excess weight loss (EWL) has been reported and 0.07% respectively), the male gender (male:female to be 47–70% in long-term series (16). Unfortunately, ratio of 4.7:01) and super obese subjects (range, 0.8–1.2%). there is a relative lack of randomized controlled trials with Open cases were considered those undergoing bariatric long-term results addressing this primary endpoint. In the surgery via laparotomy, while conversions were defined as controlled Swedish Obesity Study (SOS), patients were conversion from a laparoscopic procedure to an open prospectively followed over 20 years and those who (conventional) surgery (24). Similarly, a prospective, underwent bariatric surgery retained 18% of weight loss multicenter, observational study of 30-day outcomes in compared to 1% in the non-surgical group. The mean 4776 consecutive patients undergoing bariatric surgical 20-year weight reduction was 15% for AGB and 25% for procedures reported a comparably low perioperative RYGB patients (14). A systematic review conducted by mortality rate of 0.3% (8). O’Brien et al. (17) detected sustained EWL O50% for AGB After bariatric surgery, cardiopulmonary compli- and RYGB at 8 and 10 years respectively. cations such as myocardial infarction and pulmonary Malabsorptive procedures such as BPD and RYGB embolism are the major causes of mortality, representing achieve a greater percentage of EWL and more durable 70% of all deaths (25). The overall mortality rate for RYGB weight loss when compared to purely restrictive performed in centers of excellence is 0.4% (8). The most operations. However, this benefit comes at a cost of serious procedure-specific early complication after RYGB is higher complications rates. Specifically, BPD provides anastomotic leakage, with an incidence ranging from 0.1 the greatest weight loss in most published series but also to 5.6%. Patients at higher risk are those with higher BMI, has higher complication rates than less aggressive bariatric older age, males, with multiple comorbidities, smoking, www.eje-online.org Downloaded from Bioscientifica.com at 09/30/2021 11:37:21PM via free access Review R Corcelles and others Bariatric surgery 174:1 R21 or prior revision operations. AGB is a safe procedure with nutritional complications is mandatory following these 0.3% or less mortality rate (26). However, late compli- procedures (23). cations such as band slippage, erosion, migration, port infection and gastroesophageal perforations are well documented and occur in about 20% of patients (27). Metabolic outcomes of bariatric surgery In addition, long-term weight loss failure rates of over Effects on glycemic control 50% have been reported, and this has led to a significant increase in revisions of AGB to RYGB or SG (28). Substantial evidence from observational data indicates Procedure-specific late complications presenting clini- that bariatric surgery is very effective in controlling T2DM, cally as bowel
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